In the morning of the first day of HLTH 2018, Jonathan Bush of athenahealth explained why doctors hate their jobs and how to fix that. A few sessions later, two Walmart VPs reminded everyone that the American healthcare system is still a mess and that "bad doctors" are a big part of that problem. The general tone of the Walmart session—"The End of Provider Entitlement"—was full of damning data and clearly restrained anger. The next step in the company's healthcare transformation is to build care networks that exclude doctors who don't practice evidence-based medicine.
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Walmart's plan was the polar opposite of athenahealth's ideas for improving the healthcare system: Make doctors happier. Bush shared survey results that showed 63% of doctors are not engaged in their work. Burnout combined with a physician shortage isn't good news for patients. Athenahealth's research identified three factors driving this unhappiness: Resources, tools, and latitude. He traced the source of the last item to doctors selling their practices to larger health systems.
"In the last 8 years, docs have lost a lot of freedom," Bush said. "That went away when they sold their practice."
Bush said that to solve the physician burnout problem the healthcare system must find other opportunities for doctors to use their training and experience to make treatment decisions.
"We must replace the latitude docs lost with mergers with some other place where latitude is useful and satisfying to replace that level of engagement," he said.
Marcus Osborne, the vice president of health transformation at Walmart, sees that latitude as the root cause of the problems in healthcare: The wrong care, not enough care, and low value. Walmart has crunched the data from its Centers of Excellence Network healthcare program, and Osborne and his colleague Lisa Woods were horrified and angered by the results.
Walmart has used this analysis to compare recommendations from local doctors with the assessment of physicians in the Centers of Excellence Network. Woods said that their data shows overtreatment and misdiagnosis at higher rates than the national levels.
"Associates that go to a home doctor and are told they need surgery but when they get a second opinion at a Center of Excellence, over 50% are told they don't need surgery," said Woods, senior director of health care benefits.
With the Centers of Excellence program, employees with particular health conditions can get care at facilities selected by Walmart. The cost is covered 100% in addition to travel costs for the employee and a caregiver. This program covers organ transplants, spine surgery, joint replacement, treatment for certain cancers, and weight loss surgery.
Among associates who visit and use the network for cancer treatment, 5% get a new treatment plan or an adjusted plan and 10% get a new diagnosis, Woods said.
"We also have associates who have been told that they have cancer and when they get to Mayo, they learn they don't have cancer," Woods said.
The next phase in this transformation is to shift this "serve the customer" focus to the local healthcare scene. Walmart has started by opening primary care clinics, working with partners to deliver dental care and with Quest Diagnostics to provide testing.
The next step in this strategy shifts the focus to doctors. Osborne said the company plans to describe the immediate next step as building provider networks.
"We are going to build optimized networks and drive utilization to the highest value providers," he said. "We will build networks that realize some providers just won't cut it and won't get any value from the network."
Just as Walmart has forced its suppliers to be efficient and low cost, the company could force out of the marketplace doctors who don't practice evidence-based medicine. Current players in the marketplace (medical associations, insurance companies, state insurance boards) haven't found a way to accomplish this. An analysis by MedPageToday and the Milwaukee Journal Sentinel found that state medical boards are not using a national database designed to make it easy to spot doctors who have been found guilty of malpractice. That analysis showed that in 2017, 30 of the nation's 63 state medical boards checked the database fewer than 100 times. In 2016 a study suggested that medical errors are the third leading cause of death in America, after cancer and heart disease.
"Our customers want access to affordable healthcare and, by god, we are going to give it to them," Osborne said. "This is not just about price but the total package: Appropriate care, value, and price."
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Veronica is an independent journalist and communications strategist. For more than 10 years, she has covered health and healthcare with a focus on innovation and patient engagement. She led AIR Louisville, a three-year digital health project focused on asthma. The team enrolled 1,100 participants, recruited 7 employers partners and collected 250,000 data points about medication use. Veronica also was the editor of MedCity News for three years. You can reach her on Twitter @vmcombs.